Saturday, August 27, 2011

Feds to investigate Medicaid orthodontics fraud in Texas

For the past six months, News 8 investigations have revealed hundreds of millions of dollars of questionable Medicaid spending on braces for children in Texas.

Now federal investigators are auditing the Texas Health and Human Services Commission, which controls those funds. Taking the lead in the audit is the Office of Inspector General of the U.S. Department of Health and Human Services.

In a letter to the state, the inspector general says it will examine the "authorization process for orthodontic treatment" under Texas Medicaid. "The objective of our audit," the letter continues, "is to review the State's controls to ensure that only medically necessary orthodontic cases are paid." The time period covered by the audit is September 1, 2008 through May 28, 2011.

A News 8 investigation revealed that during that period, Texas taxpayers spent $424 million on orthodontic treatment for children under Medicaid. Taxpayers spent $100 million in 2008, $140 million in 2009, and $184 million in 2010, state records show.

Last year, Texas spent as much as the other 49 states combined.

The expenditure of Medicaid money on orthodontic treatment is controversial. The American Association of Orthodontists says scarce Medicaid money should only be used on cases of severe deformities, cranial-facial problems and cleft palates. For years, the AAO has voiced this opinion on Capitol Hill.

Dr. Christine Ellis, who teaches at UT Southwestern Medical Center, has gone to Washington twice to try to convince lawmakers to curtail Texas Medicaid orthodontics payments and redirect that money for more urgent needs.

She is one of dozens of dentists who've urged cuts in cosmetic orthodontics under Medicaid.

"There's no response," Ellis said. "No one is putting the brakes on this thing."

Records indicate that if state regulations were followed, Felkner personally approved 18,898 children under 12 years of age for braces under Medicaid last year. The under-twelve group requires special review because children that age may not yet have their permanent teeth.

In addition to the under-12 group, TMHP approved another 60,000 children over 12 for orthodontic treatment last year.

Texas taxpayers paid $184 million in all.

News 8 has tried to interview Dr Jerry Felkner for weeks. He did not return our calls.

In a parking lot outside TMHP facilities in Austin, Felkner refused to be interviewed. He drove away in his pickup truck saying he was on his way out of town.

Billy Millwee of the Texas Health and Human Services Commission supervises Felkner and TMHP. Millwee consented to a television interview after several months of requests for comment through his office.

He said he had seen none of News 8's reports revealing hundreds of millions of dollars in orthodontic expenditures, and had read only some of them, "as I have time."

Millwee said he's been working with the TMHP program for a decade. He said his office noticed an increase in Medicaid orthodontic claims in 2007 after a lawsuit ruled that Texas children needed improved access to health care under Medicaid.

He said Texas children do not receive cosmetic braces on their teeth under Medicaid. Many dental professionals argue that they do, because orthodontics is essentially a cosmetic procedure.

Texas spent $184 million on Medicaid orthodontics last year; that's nine times as much as California, which spent $19.5 million.

One state's program is not another's, Millwee said.

As for the 18,898 children under 12 who were approved for treatment last year, he said he "didn't know" if it was physically possible for one man, Dr. Felkner, to personally approve all of the cases.

Millwee said TMHP employed several "dental consultants" who might be helping. Millwee did not know who those consultants are, their qualifications, or what they do.

News 8 requested to see and film the TMHP dental review facilities in Austin months ago. We were told that was impossible, because it would compromise the privacy of Medicaid recipients.

"There's probably more visits being made (to orthodontists) than should be made," Millwee said. He added that the state is aiding the federal Inspector General in the investigation.

Millwee said if taxpayers money had been lost, the attorney general might take action to get it back.

He said the state has a new managed care Medicaid dental program scheduled to begin next spring.